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ADVANCED BILLING

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ADVANCED BILLING

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    1. ADVANCED BILLING

    2. FEBRUARY/MARCH 2006

    3. FEBRUARY/MARCH 2006 MEDICAID POLICY MANUAL Program Policy Manuals and Billing Instructions are available from these HSD web addresses: Program manuals: http://www.state.nm.us/hsd/mad/ProgManIndex.htm Billing instructions: http://www.state.nm.us/hsd/mad/OtherDocs/BillingInstructions.htm

    4. FEBRUARY/MARCH 2006 REMITTANCE ADVICE NEWSLETTER A newsletter listing the most current issues for billing providers is updated weekly and included with the RA. This newsletter contains any changes in claims processing, systems issues, and billing tips for common billing errors.

    5. FEBRUARY/MARCH 2006

    6. FEBRUARY/MARCH 2006 COMING IN SPRING 2006 On-Line PA allows providers to check their PAs on file with ACS. These will be free services to providers. Check your RA Newsletter for more information.

    7. FEBRUARY/MARCH 2006 COMING IN SPRING 2006 On-Line Claims Inquiry will allow providers to check claim status on the Web. On-Line Eligibility Inquiry client eligibility, and prior authorization information. This is a FREE service to providers. Check your RA Newsletter for more information.

    8. FEBRUARY/MARCH 2006 ALSO IN SPRING 2006 Claim Scanning (rather than microfilming). This will speed up claims processing and eliminate the waiting period for pulling claims.

    9. FEBRUARY/MARCH 2006 Optical Character Reader Optical Character Reader (OCR). This technology provides accurate data entry, reduces errors, and allows faster claims processing, without waiting for manual data entry.

    10. FEBRUARY/MARCH 2006 Optical Character Reader OCR Do’s: Use an original, standard red-dropout form (HCFA, UB, etc.) Use machine print Use a clean, non-proportional font (such as Courier)

    11. FEBRUARY/MARCH 2006 OCR Do’s: Use black ink Print claim data within the defined boxes on the claim form Print only the information asked for on the claim

    12. FEBRUARY/MARCH 2006 OCR Do’s: Use all capital letters Use a laser printer for best results Use white correction tape for corrections

    13. FEBRUARY/MARCH 2006 OCR Don’ts: Don’t hand print or hand write your forms If you must hand print, use neat block letters that stay within field boundaries Don’t use copies of claim forms

    14. FEBRUARY/MARCH 2006 OCR Don’ts: Don’t use stamps, labels, or stickers Don’t use dashes or slashes in date fields. Don’t use fonts smaller than 8 point Don’t use a dot matrix/impact printer, if possible

    15. FEBRUARY/MARCH 2006 OCR Don’ts: Don’t use correction fluid Don’t put notes on the top or bottom of the claim form Don’t enter “none” or “NA” if there is no information; just leave the box blank Don’t fold claim forms

    16. FEBRUARY/MARCH 2006 Items of Interest The State’s HIPAA claims translator, TIE, now accepts all 3 versions of the HIPAA standard electronic claim transaction: the 837P (professional), the 837I (institutional) and the 837D (dental).

    17. FEBRUARY/MARCH 2006 Items of Interest IMPORTANT NOTICE ELECTRONIC CLAIMS ARE NO LONGER ACCEPTED IN THE NSF AND ACE$ FORMATS. ONLY HIPAA COMPLIANT CLAIMS IN THE 837 FORMAT SUBMITTED THROUGH THE STATE TRANSLATOR WILL BE ACCEPTED FOR ELECTRONIC CLAIMS, WHICH INCLUDES PAYERPATH.

    18. FEBRUARY/MARCH 2006 Items of Interest Behavioral Health Statewide Entity – Effective for DOS after 6/30/2005, ACS no longer pays for most services provided by behavioral health providers. All Medicaid eligibles, even those in SALUD!, are enrolled in the “statewide entity”.

    19. FEBRUARY/MARCH 2006 Items of Interest The ONLY behavioral health services ACS pays are crossover claims that Medicare has paid as primary.

    20. FEBRUARY/MARCH 2006 Items of Interest Noted Issue: ACS is denying behavioral health crossovers from Medicare for exception 0101 – Claim DOS span managed care enrollment period. This issue is currently being worked for Medicare part A claims. When this issue is corrected, these claims will be reprocessed.

    21. FEBRUARY/MARCH 2006 Items of Interest Claims for Medicare B were corrected and reprocessed. However, if you have claims that were not addressed in the reprocessing, contact our PR helpdesk with the TCN number to find out if there were other denials connected with that claim that will need to be addressed before the claim can be reprocessed.

    22. FEBRUARY/MARCH 2006 Items of Interest State Coverage Insurance (SCI) is a program to increase insurance coverage among workers whose employers don’t offer health insurance and among the self-employed. SCI is NOT Medicaid even though clients are given a category of eligibility by ISD – 062, 063, or 064. ACS and SALUD! MCOs will ABSOLUTELY NOT pay claims for SCI enrollees.

    23. FEBRUARY/MARCH 2006 Items of Interest SCI enrollees are NOT issued NM Medicaid cards. They may be issued insurance cards by the SCI Health Plan they have enrolled in. If the SCI eligible is enrolled in an SCI Health Plan, the AVRS will indicate which SCI plan he/she is in.

    24. FEBRUARY/MARCH 2006 Ways to Check Eligibility Medicaid Eligibility Verification Services (MEVS) – See handout for list Automatic Voice Response System (AVRS) – (505) 246-2219, (800) 820-6901 Eligibility Help Desk – (505) 246-2056, (800) 705-4452

    25. FEBRUARY/MARCH 2006 Ways to Check Eligibility Online Eligibility Verification – ACS website – coming in late June 2006. Please note that this feature will be offered at no charge!

    26. FEBRUARY/MARCH 2006 Reasons to use the ACS AVRS Use the AVRS for Fast, Complete Eligibility Inquiries Eligibility inquiries can be quick and convenient using the AVRS. The AVRS is free! The AVRS is available 24 hours per day, 7 days per week!

    27. FEBRUARY/MARCH 2006 Ways to Check Eligibility - AVRS The AVRS gives you ALL the information you need! Medicaid eligibility Benefit limits, if any, i.e., Pregnancy only, Family Planning, and QMB Co-pay information Medicare coverage Commercial insurance coverage

    28. FEBRUARY/MARCH 2006 Ways to Check Eligibility - AVRS SALUD! enrollment information * NMRx enrollment information The AVRS gives you an “audit” number that can be used to trace back to the inquiry record should there be a discrepancy (a call to our help desk cannot be traced back should there be a discrepancy.)

    29. FEBRUARY/MARCH 2006 Ways to Check Eligibility - AVRS The AVRS gives you “real time” information. It uses exactly the same, “real time” information a help desk representative sees. The AVRS allows 10 inquiries per call! NO wait time on the AVRS!

    30. FEBRUARY/MARCH 2006 Ways to Check Eligibility - AVRS Before calling the eligibility help desk, please consider using the AVRS. For full instructions on how to use the AVRS, please go to the following web address: http://nmmedicaid.acs-inc.com/pubs.html

    31. FEBRUARY/MARCH 2006 ELIGIBILITY Medicaid clients not in SALUD! are covered by Medicaid’s fee-for-service program. These are the claims ACS processes and deals with on a day-to-day basis.

    32. FEBRUARY/MARCH 2006 ELIGIBILITY Babies born to moms who are in SALUD! on the baby’s date of birth are automatically a member of the same SALUD! for their birth month and (usually) the following month. The parents can switch the baby to another MCO after birth month, but this is rare.

    33. FEBRUARY/MARCH 2006 ELIGIBILITY When a child is born to a SALUD!-enrolled mother, there can be a few days of lag time between the addition of the child’s Medicaid eligibility to Omnicaid and the creation of the SALUD! enrollment span in Omnicaid.

    34. FEBRUARY/MARCH 2006 ELIGIBILITY So, a provider inquiring on the baby’s eligibility may find that the child has Medicaid eligibility but no SALUD! enrollment. This does not mean the baby will not be made a SALUD! member retroactively.

    35. FEBRUARY/MARCH 2006 ELIGIBILITY Since a child born to a mother who is enrolled in SALUD! on the child’s date of birth is ALWAYS a SALUD! member, it is important to promptly determine whether the mother is a SALUD! member at the time the child is born.

    36. FEBRUARY/MARCH 2006 ELIGIBILITY If this is the case, then you can be confident the SALUD! enrollment for the baby will be made retroactive to the child’s birth month.

    37. FEBRUARY/MARCH 2006 ELIGIBILITY Newborn babies born to moms who are NOT in SALUD! on the baby’s date of birth are in fee-for-service Medicaid until they are enrolled in SALUD! by the normal enrollment process (assuming they are not exempt from being in SALUD!).

    38. FEBRUARY/MARCH 2006 ELIGIBILITY When a baby is fee-for-service at birth and remains in the hospital and is enrolled in SALUD! during the hospital stay, the inpatient charges and services are covered by fee-for-service not SALUD!.

    39. FEBRUARY/MARCH 2006 ELIGIBILITY The SALUD! MCO ONLY becomes responsible once the baby is discharged from the inpatient hospital stay.

    40. FEBRUARY/MARCH 2006 ELIGIBILITY If you have a client that was in fee-for-service at birth and becomes SALUD! during the hospital stay, you will receive the following denial on the claim:

    41. FEBRUARY/MARCH 2006 ELIGIBILITY 0101 – Service Dates Within Managed Care Enrollment Period The client is in managed care on some or all of the dates of service on the claim.

    42. FEBRUARY/MARCH 2006 ELIGIBILITY Submit the claim on paper with a cover letter on top stating that the client was inpatient before being enrolled in SALUD!. Submit to the attention of a Field Representative.

    43. FEBRUARY/MARCH 2006 LIMITED CATEGORIES OF ELIGIBILITY 029 – Family Planning 035 – Pregnancy Related 041, 044 – Qualified Medicare Beneficiary (QMB)

    44. FEBRUARY/MARCH 2006 LIMITED CATEGORIES OF ELIGIBILITY 029 – Family Planning – Covered Services Counseling services, laboratory tests, medical procedures, and pharmaceutical supplies and devices related to family planning purposes, e.g., birth control pills.

    45. FEBRUARY/MARCH 2006 LIMITED CATEGORIES OF ELIGIBILITY 029 – Family Planning – Covered Services – continued: Sterilizations, i.e., tubal ligations. Regular reproductive health exams/screenings, i.e., pap smears and sexually transmitted disease screenings.

    46. FEBRUARY/MARCH 2006 LIMITED CATEGORIES OF ELIGIBILITY 029 – Family Planning – Non-covered Services Abortions Hysterectomies Treatment services for infertility

    47. FEBRUARY/MARCH 2006 LIMITED CATEGORIES OF ELIGIBILITY 029 – Family Planning – Non-covered Services - continued Inpatient Services Management or treatment of medical conditions/ problems discovered during screenings or caused by or following a family planning procedure, i.e., treatment for STDs, ultrasounds or cervical cancer

    48. FEBRUARY/MARCH 2006 LIMITED CATEGORIES OF ELIGIBILITY 029 – Family Planning – Non-covered Services - continued Other medical conditions not family planning related.

    49. FEBRUARY/MARCH 2006 LIMITED CATEGORIES OF ELIGIBILITY 0029 – Service not Family Planning This exception will post if the client has COE 029 - Family Planning and the service is not a family planning service. Call our Eligibility Help Desk to verify status of eligibility.

    50. FEBRUARY/MARCH 2006 LIMITED CATEGORIES OF ELIGIBILITY 035 – Pregnancy Related (non-presumptive.) Covered Services are Pregnancy related services only: Prenatal care Delivery 2 months of postnatal care

    51. FEBRUARY/MARCH 2006 LIMITED CATEGORIES OF ELIGIBILITY 035 – Pregnancy Related Non-Covered Services Abortions (elective) Vision, Dental, Hearing Psychiatric/Psychological Chiropractic Plastic Surgery (elective) Anything not medically related to the pregnancy

    52. FEBRUARY/MARCH 2006 LIMITED CATEGORIES OF ELIGIBILITY 0707 – Procedure not Pregnancy Related This exception will post if the client has a COE for pregnancy related services only and the service is not a pregnancy related service. Call our Eligibility Helpdesk to verify status of eligibility.

    53. FEBRUARY/MARCH 2006 LIMITED CATEGORIES OF ELIGIBILITY 041, 044 – Qualified Medicare Beneficiary (QMB) MEDICAID covers the co-insurance and deductible on MEDICARE covered services only after MEDICARE has paid. If service is not covered by Medicare, MEDICAID WILL NOT PAY.

    54. FEBRUARY/MARCH 2006 LIMITED CATEGORIES OF ELIGIBILITY 0266 – QMB Client/Bill Crossover only Client’s COE is QMB. The claim is NOT a crossover claim. Medicaid will only cover deductible and co-insurance on QMB clients. Call our Eligibility Helpdesk to verify status of eligibility.

    55. FEBRUARY/MARCH 2006 VERIFY THIRD PARTY LIABILITY (TPL) TPL – Adding/removing clients’ TPL (Third Party Liability) resource. Call TPL Helpdesk at (505) 246-9988 ext. 195, (800) 299-7304 ext. 195.

    56. FEBRUARY/MARCH 2006 TPL Medicaid is the payer of last resort, except for clients covered by the Indian Health Service (IHS). TPL is all commercial insurance. TPL must be billed primary to Medicaid. Medicaid does not consider Medicare TPL.

    57. FEBRUARY/MARCH 2006 TPL The following slides are examples of how to fill in the TPL information for a HCFA-1500 claim and a UB92 claim, respectively.

    61. FEBRUARY/MARCH 2006 HMO/PPO CO-PAYS Effective for paper claims with dates of service beginning May 1, 2004: If the amount billed minus the amount paid by the primary insurance is greater than the co-payment amount, bill for the co-payment.

    62. FEBRUARY/MARCH 2006 HMO/PPO CO-PAYS In the “amount paid” field, enter the difference between the billed amount and the co-payment you need to collect. Enter the co-payment amount in the “net due” field. Write “HMO/PPO Co-pay Due” on the claim. Attach the TPL EOB

    64. FEBRUARY/MARCH 2006 If the amount billed minus the amount paid by the primary insurance is less than the co-payment amount, enter the exact amount paid by the primary insurance on the claim as the previous payment. Attach the TPL EOB to the claim. Do Not Write “HMO/PPO Co-pay Due” on the claim. HMO/PPO CO-PAYS

    66. FEBRUARY/MARCH 2006 MEDICARE REPLACEMENT CLAIM In the “amount paid” field, enter the difference between the billed amount and the co-payment you need to collect. Enter the co-payment amount in the “net due” field. Write “Medicare Replacement Claim” on the claim. Attach the EOB.

    68. FEBRUARY/MARCH 2006 TPL REFUNDS If a claim is paid by an insurance company or health plan, and the services were previously paid by MAD, an Adjustment/Void must be submitted immediately refunding the lower amount of either the third party payment or MAD payment.

    69. FEBRUARY/MARCH 2006 TPL REFUNDS Make sure to include all attachments necessary.

    70. FEBRUARY/MARCH 2006 CMS All claims for Children’s Medical Services (CMS) clients must have the CMS prior authorization (PA) number entered on the claim. CMS PA numbers are now 10-digits. Previously they were 8-digits, so when you include an old CMS PA number, put 2 zeros in front of the 8-digit PA number to make a 10-digit number.

    71. FEBRUARY/MARCH 2006 CMS ACS recommends that the paper authorization issued by CMS be attached to the claim form as well. This is either the CMS-309 form or the Healthier Kids Fund card.

    72. FEBRUARY/MARCH 2006 MASS ADJUSTMENTS Mass adjustments are always approved by the State. There are various reasons for mass adjustments: Rate changes for specific provider types System changes that have affected claims Specific provider issues

    73. FEBRUARY/MARCH 2006 MASS ADJUSTMENTS The TCN number for a mass adjustment will always begin with the number “4”.

    74. FEBRUARY/MARCH 2006 Sending Claims to ACS If you must bill on paper, the fastest way to get them processed is to send them to ACS’ post office boxes or to our street address. If you are simply submitting claims, do not put “Provider Relations” or “Research Department” on the envelope.

    75. FEBRUARY/MARCH 2006 Sending Claims to ACS Claims sent with “provider relations” or “research department” on the envelope are reviewed in provider relations. That can add up to 10 business days BEFORE the claims are sent to the mail room for processing.

    76. FEBRUARY/MARCH 2006 Sending Claims to ACS If you send claims to “provider relations” or the “research department”, please be sure you include a clear explanation of the problem/issue.

    77. FEBRUARY/MARCH 2006 ACUTE CARE TO ACUTE CARE PATIENT TRANSFERS When a patient is being transferred from one acute care DRG hospital to another acute care DRG hospital (patient status = 02) the facility the patient is being transferred from needs to submit the claim with a PA number for the transfer.

    78. FEBRUARY/MARCH 2006 Billing Immunizations Bill only the CPT code for the vaccine administered. You will be reimbursed for the administration of the vaccine.

    79. FEBRUARY/MARCH 2006 Billing Immunizations NM Medicaid reimburses ONLY for the administration fee when the vaccine serum is supplied by the Vaccines for Children (VFC) program. Do not bill the CPT code for the administration of a vaccine. This is not covered.

    80. FEBRUARY/MARCH 2006 MULTIPLE SURGERY CLAIMS First surgery service will pay the full fee. Second surgery service will pay 50% of the full fee. Additional service will pay 25% of the full fee.

    81. FEBRUARY/MARCH 2006 Bill the primary service on the first line. All services must be billed on the same claim. Use modifier 51. MULTIPLE SURGERY CLAIMS

    82. FEBRUARY/MARCH 2006 BILATERAL SURGERY PROCEDURE Bilateral procedures must be billed with modifier 50. A bilateral procedure is billed with modifier 50 and pays 150% of the full fee.

    83. FEBRUARY/MARCH 2006 BILATERAL SURGERY PROCEDURE Multiple bilateral procedures are billed with modifiers 50 and 51. The secondary bilateral procedure is billed with modifiers 50 and 51, and pays 50% of the full bilateral fee.

    84. FEBRUARY/MARCH 2006

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